Background and purpose Our aim was to revalidate the RACE scale, a prehospital tool that aims to identify patients with large vessel occlusion (LVO), after its region-wide implementation in Catalonia, and to analyze geographical differences in access to endovascular treatment (EVT).
Methods We used data from the prospective CICAT registry (Stroke Code Catalan registry) that includes all stroke code activations. The RACE score evaluated by emergency medical services, time metrics, final diagnosis, presence of LVO, and type of revascularization treatment were registered. Sensitivity, specificity, and area under the curve (AUC) for the RACE cut-off value ≥5 for identification of both LVO and eligibility for EVT were calculated. We compared the rate of EVT and time to EVT of patients transferred from referral centers compared with those directly presenting to comprehensive stroke centers (CSC).
Results The RACE scale was evaluated in the field in 1822 patients, showing a strong correlation with the subsequent in-hospital evaluation of the National Institute of Health Stroke Scale evaluated at hospital (r=0.74, P<0.001). A RACE score ≥5 detected LVO with a sensitivity 0.84 and specificity 0.60 (AUC 0.77). Patients with RACE ≥5 harbored a LVO and received EVT more frequently than RACE <5 patients (LVO 35% vs 6%; EVT 20% vs 6%; all P<0.001). Direct admission at a CSC was independently associated with higher odds of receiving EVT compared with admission at a referral center (OR 2.40; 95% CI 1.66 to 3.46), and symtoms onset to groin puncture was 133 min shorter.
Conclusions This large validation study confirms RACE accuracy to identify stroke patients eligible for EVT, and provides evidence of geographical imbalances in the access to EVT to the detriment of patients located in remote areas.
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Contributors MR, MM, AR_C, PC, XU, AR-C, LP, FP, JS, DC, JZ, JAK, XU, JS, and SG and other members of the Catalan Stroke Code and Reperfusion Consortium (Cat-SCR) got patients' data and revised the paper. MG, MQ, MAM, and XJ coordinated EMS protocols and registry of data. DC, NPO, MG, MS, MAM, and XJ implemented the tool studied in this trial. SA, MR, NPO, PC, XU, and AD designed data collection tools. SA assured the quality of the prospective data registry and coordinated data extraction. DC and NPO designed the study, cleaned, and analyzed the data, and drafted and revised the paper. and, writing of the manuscript. AD supervized and revised the whole project.
Funding This work was supported by the Spanish Ministry of Health, Instituto de Salud Carlos III [name of funder] grant number FIS PI 16/01849.
Competing interests Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Correction notice Since this paper was first published online, data in the abstract has been updated.
Patient consent for publication Not required.